NU 6541 WK 3 SOAP -Primary Care

NU 6541 WK 3 SOAP -Primary Care

NU 6541 WK 3 SOAP -Primary Care of Adolescents and Children

Week 3 SOAP note- Follow up Evaluation

Patient Initials: ___AH____               Age: ___12____                                 Gender: ___F____

 

SUBJECTIVE DATA:

Chief Complaint (CC):  Episodes of altered mental status, follow up from recent hospitalization

History of Present Illness (HPI):  12-year-old African American female brought to clinic with mother for follow up evaluation after hospitalization. Two days prior, patient was at school with she became altered and had episodes of jerking movements. …

Medications:

…

Imipramine 25mg PO PRN- Mother reports that she occasionally takes this is she drinks a lot prior to bed. Last dose was 1 week prior to event occurring.

Trazodone PRN

Allergies: NKDA

Past Medical History (PMH):

Autism, …

Past Surgical History (PSH):  Esophagogatroduodenoscopy …

Sexual/Reproductive History: Denies onset of menarche. Denies any sexual behavior.

Personal/Social History: 

Immunization History: 

Significant Family History: 

Lifestyle: 

Review of Systems:

General: 

HEENT: 

Neck: Denies any tenderness, pain, or swelling.

Breasts: Denies pain

Respiratory: Denies difficulty breathing, or pain.

Cardiovascular/Peripheral Vascular: …

Gastrointestinal: …

Genitourinary: Denies any pain or trouble with urination.

Musculoskeletal: …

Psychiatric: …

Neurological: …

Skin:   Denies any rashes or sores.

           Hematologic: Denies any bleeding. Mother denies bleeding disorders.

Endocrine: Denies excessive thirst. Mother states that she must encourage child to drink.

Allergic/Immunologic: Patient has seasonal allergies which she takes medication for.

 

OBJECTIVE DATA:

Physical Exam:

Vital signs: …

General: …

HEENT: …

Neck: Trachea is midline. No JVD. No masses or abnormalities present. Lymph nodes are without enlargement.

Chest: No tenderness on palpitation. No lumps or masses felt. No abnormality noted.

Lungs: Breath sounds clear and equal. Chest rise and fall symmetrical. No wheezes, rales or rhonchi present.

Heart/Peripheral Vascular: …

 Abdomen: …

Genital/Rectal: 

Musculoskeletal: 

Neurological:

Skin: 

Labs:

 

ASSESSMENT:

Diagnosis – Seizure disorder –

• Behavioral issue r/t autism disorder- These symptoms could /…
• Adverse medication effects- …
• Migraine- …

 

PLAN:

Treatment Plan: …

 

Health Promotion: …

 

Disease Prevention: …

 

REFLECTION:

During this experience, I learned that the patient’s parents are more concerned than the patient. Mother was crying during this visit, feeling depressed regarding patient and the unknown diagnosis. The patient appeared to be well on this examination. However, the patient had numerous health issues, most of which were psychiatric or behavioral. Care must also be given to not only the patient, but family (Burns, et al, 2017).  Also, during this experience, I learned that there are so many factors that go into determining a diagnosis for the patient. The symptoms of this patient were complicated, so there are things to rule out prior to an official diagnosis. The children’s hospital was unable to rule these things out prior to the office visit. Follow up evaluation is needed for this patient.

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References:

Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L.  (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier.

Burns, C. & Matson, J. (2017). An investigation of the association between seizures, autism symptomology, and developmental functioning in young children. Developmental Neurorehabilitation, 21(3). DOI: 10.1080/17518423.2018.1437842.

Eidlitz-Markus, T., & Zeharia, A. (2017). Symptoms and clinical parameters of pediatric and adolescent migraine, by gender- a retrospective cohort study. The Journal of Headache and Pain, 18 (80). DOI: 10.1186/s10194-017-0789-z.

Linke, A., Olsen, L., Gao, Y., Fishman, I., & Muller, R. (2017). Psychotrophic medication use in autism spectrum disorders may affect functional brain connectivity. Biological Psychiatry: Cognitive Neuroscience and Neuroimaging, 2 (6). DOI: 10.1016/j.bpsc.2017.06.008

Pisula, E., Pudio, M., Slowinska, M., Kawa, R., Strzaska, M., Banasiak, A., & Wolanczyk, T.  (2016). Behavioral and emotional problems in high functioning girls and boys with autism spectrum disorders: parents’ reports and adolescents’ self-reports. SAGE Journal, 21(6). Doi: 10.1177/1362361316675119.